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Dec 05 11 05:30p Reliable PetroleumA 209-845-8953 p.4 <br />RONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />4.1171111111 <br />au <br />&Q Z—aw 1:110 Utz 0:42111 <br />PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />0 TANK RETROFIHIS O PIPING REPAIR/RETROFIT :I UDC REPAIR/RETROFIT G COLD START/EVR UPGRAnF <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # �D�P <br />Facility Name <br />�~ <br />G�Q Phone <br />Address �-3 <br />6S�''tt <br />1 <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />Phone # a® _ — ® 3 <br />o <br />Contractor Name <br />°a iV°G S Phone # 01?- s. <br />T <br />Contractor Address 1 <br />CA Lic # ST 37Z> (p Class <br />R <br />A <br />Insurer �' <br />Work Comp# (?p(Q�� �p <br />T <br />ECC Technician's Na <br />t71 4LILuo 543q -L Expiration Date.. -3--% <br />R <br />ICC Installer's Name <br />iAa I, ,SQL Expiration pate <br />Tank syste <br />.Le. 87 piping sump, 91 le <br />work area Tank Size Chemicals Stared Currently <br />deteanr, UDC 112, eta} <br />Date UST <br />Installed <br />T <br />® <br />77 <br />y <br />Go�sq,Uytf <br />N <br />n 1 <br />y,Lrr <br />_x <br />K <br />--1,0222 , ! i. <br />P <br />�_ ApF roved Approved with conditions Disapproved <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name <br />I JaA^ <br />Date_ 1 q <br />APPLICANT MUST PERFORM ALL 1A DRK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTi L HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I <br />THE PERFORMANCE OF THE WORK <br />WORKER'S COMPENSATION LAVdS <br />TI <br />CERTIFY THA" IN <br />FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />DF CALIFORNIA." CONTRACTOR'S HIRING OR SURCONTPtAr.TINC QIr-MATURG Cr.RTIMCC The rOLLOWNO. "I <br />IAT IN TI1e FTWOMtvrrrvt;t VI- I <br />OF CALIFORNIA.' <br />OCRTR• r <br />WUKK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />Appli :snfs Signature <br />T la i1]tITTrn A4r r !h AC _ ►1 <br />BILLING INFORMATION: <br />Indicate the responsible pa to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated belowis different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by ignature and date below. <br />ADDRESS 11 Q3 <br />SIGNATURE <br />EH230036 (revised 0811/11) <br />2 <br />;3 <br />